Britain is getting it wrong on heart disease. Here is how we can fix it

In recent years Britain has seen a significant fall in deaths from cardiovascular disease — that is, diseases affecting the heart and circulation. Between 2000 and 2007 the number of deaths from coronary heart disease dropped by 37 per cent. That’s the good news. The bad news is that our approach to cardiovascular disease is still failing in two key areas.

The first is in treating patients who already have a disease. For these patients achieving therapeutic targets on cholesterol is crucial. In recent years, several research studies led by Professor David Wood found that a large number of coronary patients did not meet therapeutic goals set out in international scientific guidelines — that is, getting total cholesterol below four millimoles per litre and LDL cholesterol below two millimoles per litre.

The second failing is in preventing cardiovascular disease in patients who are at high risk. This is 15 million people in the UK. If these patients were treated with aspirin, a statin and two blood pressure lowering drugs, many premature deaths would be averted.

In fact only one in three of these patients receive statins. Instead statins are handed out to lots of other patients who don’t need them. One study found that they were inappropriately prescribed to one in 10 low-risk patients.

So why aren’t we treating the right patients? One problem is that the major private healthcare providers get distracted by offering screenings that aren’t useful. Full-body MRI or CT scans, electrocardiograms, tests of kidney or liver function — all these lack any proven benefit for patients without symptoms (asymptomatic patients).

Instead we should be focusing on tests that actually provide a diagnosis rather than merely show up slight abnormalities which may be irrelevant to health. An example of the second kind of test is ambulatory blood pressure monitoring in patients with abnormal blood pressure readings.

One option for patients is the NHS free health check. This is open to everyone over the age of 40. Unfortunately, uptake has been limited and a recent study found it did not have a significant impact in reducing cardiovascular disease mortality and morbidity. The health check also does not entirely follow guidelines for prevention of cardiovascular disease issued by international bodies. Imaging, for instance a CT scan for coronary calcium, is not offered to re-classify risk.

The best assessment of cardiovascular disease risk is offered at NHS lipid clinics which are generally attached to teaching hospitals. A map of where these are around the UK can be found here. Patients must ask their GP for a referral.

This is something I would encourage for everyone who is uncertain about their risk or is not sure if they should be taking statins.

A greater awareness of risk and of what we can do to lower it would make a significant difference in the fight against cardiovascular disease.

Success in this area of medicine would make a huge difference to NHS finances too. In the United States the cost of cardiovascular disease is predicted to triple in the next 20 years, from $273 billion to more than $800 billion a year. Britain is likely to follow a similar trajectory. But cardiovascular disease is preventable, and if we can prevent more of it then we can also free up large amounts of funding for other parts of our health service. To this end, setting up more lipid clinics should be seriously considered. The major investment would not be in the equipment, which is now relatively inexpensive and portable, but in trained staff.

  • stevie gee

    Dismal analysis that reeks of bias. NHS lipid clinics, really? You obviously know nothing about the real NHS. Most centres have capacity for a few hundred patients a year and there are fewer than 200 centres in England. ‘Do the Math’ as the annoying phrase goes.

    This problem has nothing whatsoever to do with private healthcare providers and everything to do with the ancient, backward model of the NHS.

    As a cardiologist, I find it very difficult to get any of my patients onto the drugs that are recommended by current clinical trials, international guidelines and me. That is nothing to do with lipid clinics, health checks or private healthcare and everything to do with the entirely outlying model of UK healthcare, where the state decides what is good for you and you had better agree with it or else.

  • stevie gee

    I thought I was the first to comment. As a consultant cardiologist, I thought my comment would be at least tolerated, not deleted, but perhaps those lefties are right and Comment really is only Free in the BBC house mag.

  • FDL
  • FDL

    Solid Evidence Backs Heart Attack Prevention- An overview of systematic reviews shows that high-quality evidence underlies the choice of drugs in the Million Hearts Program for primary prevention of atherosclerotic cardiovascular disease. The overview of systematic reviews was published in JAMA Cardiol 2016, and demonstrates high quality evidence to support aspirin, BP-lowering therapy, and statins for parimary cardiovascular disease prevention and tobacco cessation drugs for smoking cessation.

    • Tarek

      Th evidence of statins for primary prevention is far from high quality even if the Cochrand review helpfully endorsed it. Minimal change in overall mortality, high NNT and higher incidence of side effects mean there are better ways to ameliorate risk

      • FDL

        Drugs for Primary Prevention of Atherosclerotic Cardiovascular Disease

        An Overview of Systematic Reviews
        Kunal N. Karmali, MD, MS1,2; Donald M. Lloyd-Jones, MD, ScM1,2; Mark A. Berendsen, MLIS3; David C. Goff Jr, MD, PhD4; Darshak M. Sanghavi, MD5; Nina C. Brown, MPH, CHES5; Liliya Korenovska, PhD6; Mark D. Huffman, MD, MPH1,2,7
        [+] Author Affiliations
        JAMA Cardiol. Published online April 27, 2016. doi:10.1001/jamacardio.2016.0218 Text Size: A A

        Importance The Million Hearts initiative emphasizes ABCS (aspirin for high-risk patients, blood pressure [BP] control, cholesterol level management, and smoking cessation). Evidence of the effects of drugs used to achieve ABCS has not been synthesized comprehensively in the prevention of primary atherosclerotic cardiovascular disease (ASCVD).

        Objective To compare the efficacy and safety of aspirin, BP-lowering therapy, statins, and tobacco cessation drugs for fatal and nonfatal ASCVD outcomes in primary ASCVD prevention.

        Evidence Review Structured search of the Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment Database (HTA), MEDLINE, EMBASE, and PROSPERO International Prospective Systematic Review Trial Register to identify systematic reviews published from January 1, 2005, to June 17, 2015, that reported the effect of aspirin, BP-lowering therapy, statin, or tobacco cessation drugs on ASCVD events in individuals without prevalent ASCVD. Additional studies were identified by searching the reference lists of included systematic reviews, meta-analyses, and health technology assessment reports. Reviews were selected according to predefined criteria and appraised for methodologic quality using the Assessment of Multiple Systematic Reviews (AMSTAR) tool (range, 0-11). Studies were independently reviewed for key participant and intervention characteristics. Outcomes that were meta-analyzed in each included review were extracted. Qualitative synthesis was performed, and data were analyzed from July 2 to August 13, 2015.

        Findings From a total of 1967 reports, 35 systematic reviews of randomized clinical trials were identified, including 15 reviews of aspirin, 4 reviews of BP-lowering therapy, 12 reviews of statins, and 4 reviews of tobacco cessation drugs. Methodologic quality varied, but 30 reviews had AMSTAR ratings of 5 or higher. Compared with placebo, aspirin (relative risk [RR], 0.90; 95% CI, 0.85-0.96) and statins (RR, 0.75; 95% CI, 0.70-0.81) reduced the risk for ASCVD. Compared with placebo, BP-lowering therapy reduced the risk for coronary heart disease (RR, 0.84; 95% CI, 0.79-0.90) and stroke (RR, 0.64; 95% CI, 0.56-0.73). Tobacco cessation drugs increased the odds of continued abstinence at 6 months (odds ratio range, 1.82 [95% CI, 1.60-2.06] to 2.88 [95% CI, 2.40-3.47]), but the direct effects on ASCVD were poorly reported. Aspirin increased the risk for major bleeding (RR, 1.54; 95% CI, 1.30-1.82), and statins did not increase overall risk for adverse effects (RR, 1.00; 95% CI, 0.97-1.03). Adverse effects of BP-lowering therapy and tobacco cessation drugs were poorly reported.

        Conclusions and Relevance This overview demonstrates high-quality evidence to support aspirin, BP-lowering therapy, and statins for primary ASCVD prevention and tobacco cessation drugs for smoking cessation. Treatment effects of each drug can be used to enrich discussions between health care professionals and patients in primary ASCVD prevention.

        • Tarek

          I’ve read most of the guidance but thank you very much for taking the time to collect all the references in one place.